BECK COGNITIVE THEORY OF DEPRESSION

The cognitive theory described by Beck (16, 34) evolved from his empirical observation of depressed patients descriptions of their thought content through verbalization. Cognitive psychotherapy takes the form of helping patients become aware of their cognitive distortions or cognitive errors and the underlying assumptions of these thoughts. The patient is then encouraged to seek evidence by which to support or refute these cognitive assumptions and to modify assumptions based on a more balanced view of all available information. There is a welloperationalized, manualized treatment procedure designed to replace maladaptive cognitive processes with more adaptive cognitions (18). Cognitive therapy of depression has been widely studied, and meta-analyses of its efficacy have found it to satisfy clearly the criteria for evidence-based treatment (35, 36). Several randomized controlled trials have shown that, when implemented by experienced therapists, it is as effective as pharmacotherapy (37), regardless of the severity of depressive symptoms, and may be even more effective than pharmacotherapy in preventing relapse of depressive episodes (38). The cognitive theory underlying this treatment, however, has been less well studied (39). Although there are many components of cognition that are important to cognitive depression theory, we focus on the 2 cognitive constructs with well-validated measures: cognitive errors and dysfunctional attitudes. Jointly, we label these cognitive distortions. Cognitive Distortions in the Etiology of Depression Cognitive distortions in the absence of a major life stressor are thought to be quiescent. Without specific cognitive intervention, they are also thought to be relatively stable. The conjoint presence of cognitive distortions and a major life stressor, however, is expected to increase the likelihood of a depressive episode. Following from this conceptualization, cognitive distortions should be higher in depressed compared with normal control post-ACS patients, both when a depressive episode is present and when it is absent. This latter point has not yet been established in the literature. For cognitive distortions to be proximal causes for depression, they must precede the depressive episode; otherwise, they would be better conceptualized as epiphenomena. To address this question, Smith et al. (40)conducted a prospective study with a sample of 72 (nondepressed) patients with rheumatoid arthritis followed for 4 years. Cognitive distortions assessed at baseline by the Cognitive Error Questionnaire predicted significant increases in depressive symptoms 4 years later, controlling for baseline depressive symptoms. Moreover, baseline depressive symptoms did not predict changes in cognitive distortions across the study. Interestingly, increased helplessness(41) was also assessed at baseline and did not predict depressive symptom increase across the 4 years, suggesting that helplessness was not a depression proximal cause in this sample. Support for the cognitive theory of depression would also be bolstered if cognitive depression interventions led to less cognitive distortion, such that the level of distortion for successfully treated patients were normalized or closer to the level of nondepressed people. Using the Dysfunctional Attitude Scale, depressed patients have been found to have significantly higher initial levels of dysfunctional attitudes than normal controls, and after cognitive therapy, those whose depression remitted had Dysfunctional Attitude Scale scores close to the levels of normal controls in 1 study (42). In contrast, the National Institute of Mental Health Treatment of Depression Collaborative Research Program did not find that cognitive distortions were lowered most by cognitive (behavioral) therapy (43 45) compared with a drug or interpersonal therapy arm. Beck (46) and Ruehlman et al. (47) have cautioned that the correlates and causes of mildly elevated depressive symptoms or dysphoria cannot be safely assumed to be the same as those for major depression. Specifically, people with subthreshold depression are generally thought to have accurate cognitive perceptions of the stressful life event, resembling adjustment disorder, whereas those with major depression are not (48). Cognitive theory would predict that post-ACS patients with high dysfunctional attitude scores are more likely to have more severe depressive symptoms compared with post-ACS patients with low dysfunctional attitudes. Furthermore, given that cognitive distortions appear relatively stable and increase a persons vulnerability to a major depressive episode when combined with a major life event, depressive symptoms in the presence of cognitive distortions would not be expected to spontaneously remit in this patient population. In summary, there is some evidence from a number of different designs suggesting the possibility that cognitive distortions may be a proximal cause of depression, but there is other evidence such as that from the National Institute of Mental Health trial that is troubling. From the lack of convincing empirical data on the postulates of

cognitive theory, some have expressed more global concerns about the theory; they propose that all diathesis-stress models of depression have formidable conceptual and methodological challenges that have not yet been met (49). These challenges compromise the potential usefulness of these theories to depression treatment. However, the presence of cognitive distortions in post-ACS patients, regardless of current depressive episode status, could be 1 of the markers of excess ACS and depression nonremittance risk, because in theory it should mark previous and future vulnerability to depression. Previous SectionNext Section

INTERPERSONAL THEORY OF DEPRESSION

The interpersonal theory of depression is based on theories emanating from the interpersonal school of psychiatry (50) and empirical data related to attachment theory and social roles (51). Interpersonal psychotherapy, developed by Klerman et al. (19), is a focused, short-term, time-limited therapy that emphasizes the current interpersonal relations of the depressed patient. The efficacy of interpersonal psychotherapy treatment for major depression has been demonstrated in several controlled comparative depression treatment trials (45). For example, in a depressed geriatric population, interpersonal psychotherapy has shown some advantages over tricyclic antidepressant therapy because of attrition in the latter intervention, in part because of medication side effects (52). A brief psychosocial intervention, based on interpersonal psychotherapy, to treat medical patients in primary care has also demonstrated a reduction in depressive symptoms(19). Interpersonal psychotherapy has been successfully modified and used with older patients (53) and with subsyndromally depressed hospitalized elderly patients (54). Frank et al. (55) also demonstrated the efficacy of maintenance interpersonal psychotherapy, a modified interpersonal psychotherapy version focusing on the prevention of depression in remitted patients, in a long-term randomized controlled trial. Interestingly, they also showed that treatment specificity (the ability of patients and therapists to focus consistently on interpersonal concerns and the techniques of interpersonal psychotherapy to the exclusion of other treatment elements) was essential for successful depression relapse prevention. Interpersonal psychotherapy focuses on the intuitively appealing concept that events in ones psychosocial environment affect ones mood and vice versa. When major events occur, mood worsens, and depression may result. Conversely, depressed mood compromises ones ability to handle ones social roles, generally leading to further negative events and ongoing interpersonal distress (56). The crux of interpersonal psychotherapy is to demonstrate empirically a link between mood and interpersonal issues that appear temporally and thematically related to the onset and maintenance of depression (19). Once a patient understands this link and identifies the specific interpersonal area that is currently problematic, the therapist and patient work together to alter the interpersonal environment so that the depression will lift (56). The patient and therapist agree on 1 of the following 4 interpersonal problem areas that will be the focus of the depression treatment: a) grief or complicated bereavement, b) role dispute or ongoing disagreements with a significant person in the patients life, c) a recent role transition that results in major interpersonal role changes or alterations (eg, retirement, moving, being diagnosed with a major medical illness), and d) interpersonal deficits (recurrent difficulties in social interactions, in their extreme form classified as personality disorders). Although depressed patients may fit into several or all of the 4 interpersonal problem areas, the treatment demands that 1 area (or occasionally 2) be chosen as the primary target for intervention. Presence of Interpersonal Problems in the Etiology of Depression Numerous studies have found interpersonal problems as reflected in divorce, marital problems, and negative partner and child interactions to be significantly more prevalent or elevated in depressed people (57, 58). However, it is still unclear whether interpersonal problems precede depressive episodes rather than co-occur with or even result from depressive mood states. On a variety of interpersonal functioning indicators, Hammen and Brennan (58) compared 83 women with unipolar major depression or dysthymic disorder, 271 women who were not currently in a depressive episode but who had past histories of either DSM-IV depression diagnosis, and 458 neverdepressed women. As expected, the currently depressed women had the worst scores on all interpersonal indicators. Compared with the never-depressed group, and controlling for current subclinical depressive symptoms and socioeconomic status, the past depression women reported a more frequent use of coercive interpersonal tactics, more interpersonal conflicts, less secure attachment representations of relationships, and more dysfunctional personality traits. Moreover, their close relationship functioning was found to be more dysfunctional by interviewers, and the marital satisfaction of the womens spouses was worse. Although cross-sectional, at least this 1 set of results suggests that impoverished relational skills and dysfunctional representations of relationships are proximal causes of depression that persist even in the absence of clinically relevant depressed mood.

Interpersonal psychotherapy explicitly focuses on the here and now of these interpersonal problems, and thus appears applicable to a wide range of patient populations with interpersonal problems. However, little research is available demonstrating that the tenets and postulates of interpersonal theory are supported. For example, it is not yet clear that the reduction or prevention of depressive symptoms is mediated through changes in 1 of the 4 interpersonal problem areas, such as relational functioning. Finally, the efficacy of this therapy in medically ill, mildly depressed patients has yet to be clearly established. To conclude, the interpersonal theory has not been extensively tested for either increased presence of interpersonal problems before the depressive symptoms or for evidence that interpersonal psychotherapy reduces the identified interpersonal problem. The beneficial effect of interpersonal psychotherapy on depressive symptomatology is well established. Based on this theory, post-ACS patients with the presence of a role transition, or loss, or interpersonal deficits will be more likely to show elevated depressive symptoms. A second group at risk may be patients for whom the cardiac event itself represents a major loss or role transition. Patients with this depressogenic vulnerability may not be as severely depressed as those with cognitive distortions, but their depressive symptoms are also unlikely to remit spontaneously without intervention, because the defined interpersonal problems and interpersonal functioning deficits are considered relatively stable. Previous SectionNext Section

BEHAVIORAL THEORY OF DEPRESSION

The predominant behavioral theory of depression postulates that major life stressors can result in a depressive episode because they disrupt normal behavior reinforcement patterns (59). Originating from an operant conditioning paradigm, this theory views depression as the consequence of a lack of or decrease in the efficiency of positively reinforced behavior and perhaps overt punishment for behavioral initiation. This may be a result of a decrease in the availability of reinforcing events, ones personal skills to act on the environment, the impact of certain types of events, or a combination of these. In addition, the mobilization of support from family and other social networks may result in a negative feedback loop of social reinforcement for depressive behaviors (eg, social withdrawal, positive social reinforcement for withdrawal, further withdrawal). In other words, in times of major stress from unexpected events, people may experience a low rate of positive reinforcement for mood-enhancing behavior and a higher rate of positive reinforcement for depressive behavior. The behavioral treatment that derives from this theory of depression involves helping patients increase their frequency and quality of pleasant activities. It has been found that depressed patients have low rates of pleasant activities and obtained pleasure; their mood covaries positively with rates of pleasant activities and inversely with rates of aversive activities (60). Finally, behavioral treatment for depression has been shown to be efficaciousto reduce depressionin multiple randomized controlled trials (59, 61). Lewinsohn (20) discussed dysphoria (defined by him as the presence of low levels of negative mood symptoms) as the affective state that results when few environmental positive reinforcers are available for a persons behavior. Older people, and particularly patients hospitalized for a life-threatening event, are at greater risk than people at other points in the life cycle, with the possible exception of children, for being placed in situations in which their own behavior has little effect on the environment or the behavior of others (62). Thus, the disruption of the pattern of reinforcement for self-initiated behaviors that occurs when a patient experiences an ACS event is pertinent to the behavioral theory of depression. Frequently, ACS risk factor management recommendations compound this problematic behavior pattern. For example, patients who experience smoking or eating a saturated fat-rich meal as positively reinforcing frequently report that most of the pleasant or pleasurable activities in their lives have now been restricted or removed because of their health-damaging consequences. Although therapeutic approaches to depression more often involve both cognitive and behavioral components than either 1 alone, component analyses have shown that behavioral activation appears to be as effective as cognitive therapy for altering negative thinking and dysfunctional attributional styles and for producing change in depressive symptoms and course of relapse (63). Lack of Pleasant Events in the Etiology of Depression The behavioral theory of depression posits that the specific proximal cause for depression is the interaction of the patient behavior and the reinforcement schedule of the environment. The frequency of pleasant events is lower in depressed compared with normal controls (64, 65), mood covaries with this frequency (60), and behavioral depression treatment increases pleasant event occurrence in those who have their depression successfully treated. For example, Wierzbicki and Rexford (65) studied the frequency and pleasantness or unpleasantness of positive and

negative events (assessed with the Pleasant Events Schedule and the Unpleasant Events Schedule) in a clinical sample of 60 people diagnosed with any DSM-III depressive disorder (major affective disorder, dysthymic depression, or atypical depression), and in a nonclinical sample of 143 undergraduate students. They found that in both samples, depression scores on the BDI were negatively related to the frequency and pleasantness of pleasant events and were positively related to the frequency of unpleasant events. Importantly, Grosscup and Lewinsohn (60) demonstrated in depressed patients that scores on daily ratings of the Unpleasant Events Schedule and Pleasant Events Schedule were associated with daily fluctuations in mood level. Moreover, during the course of a specific treatment targeted at increasing pleasant activities, a decrease in the subjective aversiveness of events was associated with clinical improvement in depression symptoms. In summary, the behavioral theory of depression postulates that low rates of positive events and therefore the absence of positive reinforcement are central to the induction and maintenance of depressive symptoms. Depressed people compared with nondepressed people have fewer pleasant events, and behavioral treatment aimed at increasing pleasant events successfully decreases depression. It is less clear whether the behavioral theory has a prediction about the course of depression in patients with ACS. One possibility is that as the time from the ACS event lengthens, the frequency of pleasant events occurrence and behavior reinforcement will naturalistically increase, and depressive symptoms will decrease. As a consequence, post-ACS patients with a behavioral reinforcement disruption as the proximal cause for their depressive symptoms will be more likely to remit spontaneously than those with the other 2 depression proximal causes. Previous SectionNext Section

INTERRELATEDNESS OF THE PROXIMAL CAUSES

In real-life clinical settings, the specific proximal causes that each theory focuses on are not treated as distinct dimensions of functioning, but rather as interrelated domains. This is supported by empirical evidence. For example, Whisman and Friedman (66) demonstrated that in a sample of 390 undergraduate students, higher levels of dysfunctional attitudes were associated with higher levels of interpersonal problems, even when controlling for negative affect. In the study of Wierzbicki and Rexford (65), higher dysfunctional attitude scores were related to less positive behavioral events and more unpleasant behavioral events in both a clinical, treatment-seeking sample and an undergraduate student sample. More importantly, both pleasant events and dysfunctional attitudes were independently associated with depressive symptoms in both samples. Although not directly tested in the Wierzbicki study, this also suggests an independent, additive effect of the presence of more than 1 proximal cause on depressive levels

Aaron Beck's Cognitive Theory of Depression Different cognitive behavioral theorists have developed their own unique twist on the Cognitive way of thinking. According to Dr. Aaron Beck, negative thoughts, generated by dysfunctional beliefs are typically the primary cause of depressive symptoms. A direct relationship occurs between the amount and severity of someone's negative thoughts and the severity of their depressive symptoms. In other words, the more negative thoughts you experience, the more depressed you will become. Beck also asserts that there are three main dysfunctional belief themes (or "schemas") that dominate depressed people's thinking: 1) I am defective or inadequate, 2) All of my experiences result in defeats or failures, and 3) The future is hopeless. Together, these three themes are described as the Negative Cognitive Triad. When these beliefs are present in someone's cognition, depression is very likely to occur (if it has not already occurred). An example of the negative cognitive triad themes will help illustrate how the process of becoming depressed works. Imagine that you have just been laid off from your work. If you are not in the grip of the negative cognitive triad, you might think that this event,

while unfortunate, has more to do with the economic position of your employer than your own work performance. It might not occur to you at all to doubt yourself, or to think that this event means that you are washed up and might as well throw yourself down a well. If your thinking process was dominated by the negative cognitive triad, however, you would very likely conclude that your layoff was due to a personal failure; that you will always lose any job you might manage to get; and that your situation is hopeless. On the basis of these judgments, you will begin to feel depressed. In contrast, if you were not influenced by negative triad beliefs, you would not question your self-worth too much, and might respond to the lay off by dusting off your resume and initiating a job search. Beyond the negative content of dysfunctional thoughts, these beliefs can also warp and shape what someone pays attention to. Beck asserted that depressed people pay selective attention to aspects of their environments that confirm what they already know and do so even when evidence to the contrary is right in front of their noses. This failure to pay attention properly is known as faulty information processing. Particular failures of information processing are very characteristic of the depressed mind. For example, depressed people will tend to demonstrate selective attention to information, which matches their negative expectations, and selective inattention to information that contradicts those expectations. Faced with a mostly positive performance review, depressed people will manage to find and focus in on the one negative comment that keeps the review from being perfect. They tend to magnify the importance and meaning placed on negative events, and minimize the importance and meaning of positive events. All of these maneuvers, which happen quite unconsciously, function to help maintain a depressed person's core negative schemas in the face of contradictory evidence, and allow them to remain feeling hopeless about the future even when the evidence suggests that things will get better